Rapid assessment

Initial management of an infant or child with a decreased conscious level is to support airway (immobilise cervical spine if trauma is suspected), breathing and circulation. A score (AVPU) has been introduced for rapid assessment of disability, particularly pre-hospital and in emergency departments. The score assesses neurological status as alert (A), responds to voice (V), responds to pain (P), or unresponsive (U) (ALSG, 2001). This scoring system, entitled the AVPU score, is simple to use and requires little training (Mackay et al 2000), allowing the observer to swiftly evaluate priorities of care without the need for additional charts or equipment. It does not, however, replace more accurate coma scales that are essential for serial assessment and evaluation of the patient’s level of consciousness.

Coma scales

Coma scales were introduced in the early 1970s in a successful attempt to standardise nursing and medical approaches to neurological assessment (Teasdale & Jennett 1974). Coma scales cover the following five main assessment criteria:

The most commonly used coma scale is the Glasgow Coma Scale (GCS). Devised by Teasdale and Jennett (1974), this is an adult scale that has also been adapted for children in recognition of the fact that verbal and motor responses must be related to the child’s age (Campbell & Glasper 1995).

There are various paediatric adaptations of the GCS, for example that of James and Trauner (1985), and its subsequent revision as the Birmingham Children’s Hospital (BCH) model, as demonstrated in Table 17.1.

Table 17.1 BCH model, paediatric adaptation of Glasgow Coma Scale

Another adapted GCS scale is known as the Paediatric Glasgow Coma Scale (PGCS) or Adelaide scale. Physicians at Adelaide Children’s Hospital first adapted it for use in paediatrics and their adaptations were to the verbal and motor responses. These were developed to correlate with expected developmental milestones of children of different ages. The adaptations themselves were minor. They expected nurses to be trained to use the tool and to be able to apply knowledge of normal development when assessing the verbal and motor components of the scale. Table 17.2 demonstrates how a nurse would be expected to interpret a score against normal, verbal developmental milestones.

Table 17.2 Paediatric Glasgow Coma Scale

The Advanced Life Support Group (ALSG, 1997) developed a simplified version of a children’s coma scale for use in children under 4 years (Table 17.3).

Table 17.3 Advanced Life Support Group children’s coma scale: <4 years

Reproduced from Lawton (1995) by kind permission.

Which scale to use is a matter of local choice according to the wishes of the multi-professional team. However, the nurse using the tool must have been given suitable tuition in how to use the tool and interpret the results, and be aware of the limitations of each scale. In addition, it must be remembered that the normal responses of a child who is developmentally delayed, or has an existing neurological deficit, may not fall within the specified age range, i.e. ‘child over 5 years’ and ‘child under 5 years’. It has been suggested that age-related scales should be replaced with criteria that reflect patients’ ‘usual ability’ to allow for infants/ children who have not achieved recognised developmental milestones (Warren 2000).

Early warning systems

Many acute children’s services are adopting Paediatric Early Warning Systems (PEWS) to assist in detecting children at risk of deterioration (Monaghan 2005). Most of these systems use age appropriate vital sign indicators to trigger intervention. PEWS scores have proved to identify patients at risk before a life threatening event occurs (Duncan et al 2006).

However, coma score evaluation is not always an integral part of PEWS documentation, therefore appropriate charting should be used in addition to detect neurological deficit according to local policy.

Applying a painful stimulus during neurological assessment

In a child who has a decreased conscious level, it is often necessary to apply a painful stimulus to evoke a response. The methods used to evoke a response differ according to Trust/hospital policies, personal preferences and expertise. Moreover, with a deteriorating conscious level, the necessity to accurately interpret a deficit in neurological status is of paramount importance so that the appropriate intervention can ensue. It is also essential that the choice of stimuli used, either peripheral or central, reflects the condition of the patient.

Frawley (1990) described the potential of damage to the nailbed following repetitive pressure assessments, thus advocating the use of side finger pressure. Following this article, many healthcare professionals adopted side finger pressure to avoid potential trauma, assuming peripheral pressure is advocated. However, many different modes of stimulus are regularly used in the paediatric setting, including squeezing the ear lobe, rubbing the sternum, pinching flesh under the arm, squeezing the shoulder and supraorbital pressure, with the most common being either nailbed or side finger pressure. No method of painful stimulus is regarded as a gold standard in the assessment of infants and children and few of the above techniques have been validated in paediatric practice.

Side finger pressure is performed by placing the child’s finger (third and fourth fingers are most sensitive) between the nurse’s thumb and a pen or pencil and gradually increasing pressure until a response is obtained (Fig. 17.1).

Figure 17.1 Side finger pressure.

Applying pressure to the nailbed is achieved in a similar way to that of side finger pressure but is contraindicated in patients with poor perfusion or reported coagulopathy. Moreover, nurses should also be aware of the limitations of ‘peripheral’ stimuli when assessing deeply comatosed patients.

Supraorbital pressure, or ‘central stimuli’, is regarded as a more accurate method of evoking response in patients in deep coma. It is particularly painful and should only be performed by staff aware of the contraindications of the procedure and who are competent and confident to do so safely. The advantage of this painful stimulus over ‘peripheral’ methods is to avoid eliciting reflex responses, particularly in the lower limbs, which could mislead the observer.

There are two factors of paramount importance when evoking a pain response in children with a diminished level of consciousness: